Scolaris Content Display Scolaris Content Display

Métodos de cierre del muñón apendicular para complicaciones durante la apendicectomía laparoscópica

Appendices

Appendix 1. Search strategy for the Cochrane Library

#1 MeSH descriptor: [Appendix] explode all trees

#2 MeSH descriptor: [Appendicitis] explode all trees

#3 MeSH descriptor: [Appendectomy] explode all trees

#4 append*:ti,ab,kw

#5 (#1 or #2 or #3 or #4)

#6 MeSH descriptor: [Laparoscopy] explode all trees

#7 (laparoscop* or minimal* invasiv*):ti,ab,kw

#8 (#6 or #7)

#9 MeSH descriptor: [Suture Techniques] explode all trees

#10 MeSH descriptor: [Surgical Staplers] explode all trees

#11 (stump or loop* or ligation or polymer* or stapl* or Roeder or Roder or clips* or sutur* or closure*):ti,ab,kw

#12 (#9 or #10 or #11)

#13 (#5 and #8 and #12)

Appendix 2. Search strategy for MEDLINE (Ovid)

1. exp Appendix/

2. exp Appendicitis/

3. exp Appendectomy/

4. append*.mp.

5. 1 or 2 or 3 or 4

6. exp Laparoscopy/

7. (laparoscop* or minimal* invasiv*).mp.

8. 6 or 7

9. exp Suture Techniques/

10. exp Surgical Staplers/

11. (stump or loop* or ligation or polymer* or stapl* or Roeder or Roder or clips* or sutur* or closure*).mp.

12. 9 or 10 or 11

13. 5 and 8 and 12

14. randomized controlled trial.pt.

15. controlled clinical trial.pt.

16. randomized.ab.

17. placebo.ab.

18. clinical trials as topic.sh.

19. randomly.ab.

20. trial.ti.

21. 14 or 15 or 16 or 17 or 18 or 19 or 20

22. Exp animals/ not humans.sh.

23. 21 not 22

24. 13 and 23

Appendix 3. Search strategy for Embase (Ovid)

1. exp appendix/

2. exp appendix disease/

3. exp appendectomy/

4. append*.mp.

5. 1 or 2 or 3 or 4

6. exp laparoscopy/

7. (laparoscop* or minimal* invasiv*).mp. 8. 6 or 7

9. exp suturing method/

10. exp suture/

11. (stump or loop* or ligation or polymer* or stapl* or Roeder or Roder or clips* or sutur* or closure*).mp.

12. 9 or 10 or 11

13. 5 and 8 and 12

14. CROSSOVER PROCEDURE.sh.

15. DOUBLE‐BLIND PROCEDURE.sh.

16. SINGLE‐BLIND PROCEDURE.sh.

17. (crossover* or cross over*).ti,ab.

18. placebo*.ti,ab.

19. (doubl* adj blind*).ti,ab.

20. allocat*.ti,ab.

21. trial.ti.

22. RANDOMIZED CONTROLLED TRIAL.sh.

23. random*.ti,ab.

24. 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23

25. (exp animal/ or exp invertebrate/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans or man or men or wom?n).ti.)

26. 24 not 25

27. 13 and 26

Appendix 4. Search strategy for Science Citation Index ‐ Expanded

#1 Topic=(append*)

#2 Topic=(laparoscop*)

#3 Topic=(stump or loop* or ligation or polymer* or stapl* or Roeder or Roder or clips* or sutur* or closure*)

#4 Topic=(random* OR controlled OR RCT OR placebo OR trial OR group* OR trial*)

#5 (#1 and #2 and #3 and #4)

Appendix 5. Criteria for risk of bias assessment in the Cochrane 'Risk of bias' tool

RANDOM SEQUENCE GENERATION

Selection bias (biased allocation to interventions) due to inadequate generation of a randomised sequence

Criteria for a judgement of ‘low risk’ of bias

Investigators describe a random component in the sequence generation process such as:

· referring to a random number table;

· using a computer random number generator;

· tossing a coin;

· shuffling cards or envelopes;

· throwing dice;

· drawing lots; or

· minimising*.

*Minimisation may be implemented without a random element, and this is considered equivalent to being random.

Criteria for the judgement of ‘high risk’ of bias

Investigators describe a non‐random component in the sequence generation process. Usually, the description would involve some systematic, non‐random approach, for example:

· sequence generated by odd or even date of birth;

· sequence generated by some rule based on date (or day) of admission;

· sequence generated by some rule based on hospital or clinic record number.

Other non‐random approaches happen much less frequently than the systematic approaches mentioned above and tend to be obvious. They usually involve judgement or some method of non‐random categorisation of participants, for example:

· allocation by judgement of the clinician;

· allocation by preference of the participant;

· allocation based on results of a laboratory test or series of tests; or

· allocation by availability of the intervention.

Criteria for the judgement of ‘unclear risk’ of bias

Insufficient information about the sequence generation process to permit judgement of ‘low risk’ or ‘high risk’

ALLOCATION CONCEALMENT

Selection bias (biased allocation to interventions) due to inadequate concealment of allocations before assignment

Criteria for a judgement of ‘low risk’ of bias

Participants and investigators enrolling participants could not foresee assignment because one of the following, or an equivalent method, was used to conceal allocation.

· Central allocation (including telephone, web‐based, and pharmacy‐controlled randomisation);

· Sequentially numbered drug containers of identical appearance; or

· Sequentially numbered, opaque, sealed envelopes.

Criteria for the judgement of ‘high risk’ of bias

Participants or investigators enrolling participants could possibly foresee assignments and thus introduce selection bias, such as allocation based on:

· using an open random allocation schedule (e.g. a list of random numbers);

· using assignment envelopes without appropriate safeguards (e.g. if envelopes were unsealed or non­opaque or were not sequentially numbered);

· alternation or rotation;

· date of birth;

· case record number; or

· any other explicitly unconcealed procedure.

Criteria for the judgement of ‘unclear risk’ of bias

Insufficient information to permit judgement of ‘low risk’ or ‘high risk’. This is usually the case if the method of concealment is not described or is not described in sufficient detail to allow a definitive judgement – for example, if use of assignment envelopes is described, but it remains unclear whether envelopes were sequentially numbered, opaque and sealed.

BLINDING OF PARTICIPANTS AND PERSONNEL

Performance bias due to knowledge of allocated interventions by participants and personnel during the study

Criteria for a judgement of ‘low risk’ of bias

Any one of the following.

· No blinding or incomplete blinding, but review authors judge that the outcome is not likely to be influenced by lack of blinding.

· Blinding of participants and key study personnel ensured, and unlikely that blinding could have been broken.

Criteria for the judgement of ‘high risk’ of bias

Any one of the following.

· No blinding or incomplete blinding, and the outcome is likely to be influenced by lack of blinding.

· Blinding of key study participants and personnel attempted, but likely that blinding could have been broken, and the outcome is likely to be influenced by lack of blinding.

Criteria for the judgement of ‘unclear risk’ of bias

Any one of the following.

· Insufficient information to permit judgement of ‘low risk’ or ‘high risk’.

· The study did not address this outcome.

BLINDING OF OUTCOME ASSESSMENT

Detection bias due to knowledge of allocated interventions by outcome assessors

Criteria for a judgement of ‘low risk’ of bias.

Any one of the following.

· No blinding of outcome assessment, but review authors judge that the outcome measurement is not likely to be influenced by lack of blinding.

· Blinding of outcome assessment ensured, and unlikely that blinding could have been broken.

Criteria for the judgement of ‘high risk’ of bias

Any one of the following.

· No blinding of outcome assessment, and the outcome measurement is likely to be influenced by lack of blinding.

· Blinding of outcome assessment, but likely that blinding could have been broken, and the outcome measurement is likely to be influenced by lack of blinding.

Criteria for the judgement of ‘unclear risk’ of bias

Any one of the following.

· Insufficient information to permit judgement of ‘low risk’ or ‘high risk’.

· The study did not address this outcome.

INCOMPLETE OUTCOME DATA

Attrition bias due to quantity, nature, or handling of incomplete outcome data

Criteria for a judgement of ‘low risk’ of bias

Any one of the following.

· No missing outcome data.

· Reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias).

· Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups.

· For dichotomous outcome data, proportion of missing outcomes compared with observed event risk not enough to have a clinically relevant impact on the intervention effect estimate.

· For continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes not enough to have a clinically relevant impact on observed effect size.

· Missing data imputed using appropriate methods.

Criteria for the judgement of ‘high risk’ of bias

Any one of the following.

· Reasons for missing outcome data likely to be related to true outcome, with imbalance in numbers or reasons for missing data across intervention groups.

· For dichotomous outcome data, proportion of missing outcomes compared with observed event risk enough to induce clinically relevant bias in intervention effect estimate.

· For continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes enough to induce clinically relevant bias in observed effect size.

· ‘As‐treated’ analysis done with substantial departure of the intervention received from that assigned at randomisation.

· Potentially inappropriate application of simple imputation.

Criteria for the judgement of ‘unclear risk’ of bias

Any one of the following.

· Insufficient reporting of attrition/exclusions to permit judgement of ‘low risk’ or ‘high risk’ (e.g. number randomised not stated, no reasons for missing data provided).

· The study did not address this outcome.

SELECTIVE REPORTING

Reporting bias due to selective outcome reporting

Criteria for a judgement of ‘low risk’ of bias

Any of the following.

· The study protocol is available and all of the study’s prespecified (primary and secondary) outcomes that are of interest in the review have been reported in the prespecified way.

· The study protocol is not available but it is clear that published reports include all expected outcomes, including those that were prespecified (convincing text of this nature may be uncommon).

Criteria for the judgement of ‘high risk’ of bias

Any one of the following.

· Not all of the study’s prespecified primary outcomes have been reported.

· One or more primary outcomes are reported using measurements, analysis methods, or subsets of data (e.g. subscales) that were not prespecified.

· One or more reported primary outcomes were not prespecified (unless clear justification for their reporting is provided, such as an unexpected adverse effect).

· One or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta‐analysis.

· The study report fails to include results for a key outcome that would be expected to have been reported for such a study.

Criteria for the judgement of ‘unclear risk’ of bias

Insufficient information to permit judgement of ‘low risk’ or ‘high risk’. It is likely that most studies will fall into this category.

OTHER BIAS

Bias due to problems not covered elsewhere in the table

Criteria for a judgement of ‘low risk’ of bias

The study appears to be free of other sources of bias.

Criteria for the judgement of ‘high risk’ of bias

There is at least one important risk of bias. For example, the study:

· had a potential source of bias related to the specific study design used;

· has been claimed to have been fraudulent; or

· had some other problem.

Criteria for the judgement of ‘unclear risk’ of bias

There may be a risk of bias, but there is either:

· insufficient information to assess whether an important risk of bias exists; or

· insufficient rationale or evidence that an identified problem will introduce bias.

Data collection form (Microsoft Word).
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Figure 1

Data collection form (Microsoft Word).

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*Lange 1993 was not retrievable following a worldwide search because the journal was published and is going out of print (see Results section).
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Figure 2

*Lange 1993 was not retrievable following a worldwide search because the journal was published and is going out of print (see Results section).

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 1 Total complications.
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Analysis 1.1

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 1 Total complications.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.
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Analysis 1.2

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.
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Analysis 1.3

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between mechanical device and ligature.
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Analysis 1.4

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between mechanical device and ligature.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 5 Hospital stay (in days) between mechanical and ligature.
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Analysis 1.5

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 5 Hospital stay (in days) between mechanical and ligature.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.
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Analysis 1.6

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.
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Analysis 1.7

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.

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Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.
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Analysis 1.8

Comparison 1 Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 1 Total complications.
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Analysis 2.1

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 1 Total complications.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.
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Analysis 2.2

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.
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Analysis 2.3

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between stapler and ligature.
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Analysis 2.4

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between stapler and ligature.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between stapler and ligature.
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Analysis 2.5

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between stapler and ligature.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.
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Analysis 2.6

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.
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Analysis 2.7

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.

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Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.
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Analysis 2.8

Comparison 2 Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 1 Total complications.
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Analysis 3.1

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 1 Total complications.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.
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Analysis 3.2

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 2 Intraoperative complications.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.
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Analysis 3.3

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 3 Postoperative complications.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between clips and ligatures.
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Analysis 3.4

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 4 Comparison of operative time between clips and ligatures.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between clips and ligature.
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Analysis 3.5

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 5 Comparison of hospital stay between clips and ligature.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.
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Analysis 3.6

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 6 Postoperative superficial infections.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.
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Analysis 3.7

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 7 Postoperative deep infections.

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Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.
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Analysis 3.8

Comparison 3 Clips versus ligature (Endoloop or intracorporeal knot), Outcome 8 Postoperative ileus.

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Comparison 4 Endoscopic stapler versus clips, Outcome 1 Total complications.
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Analysis 4.1

Comparison 4 Endoscopic stapler versus clips, Outcome 1 Total complications.

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Comparison 4 Endoscopic stapler versus clips, Outcome 2 Intraoperative complications.
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Analysis 4.2

Comparison 4 Endoscopic stapler versus clips, Outcome 2 Intraoperative complications.

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Comparison 4 Endoscopic stapler versus clips, Outcome 3 Postoperative complications.
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Analysis 4.3

Comparison 4 Endoscopic stapler versus clips, Outcome 3 Postoperative complications.

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Comparison 4 Endoscopic stapler versus clips, Outcome 4 Comparison of operative time between stapler and clips.
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Analysis 4.4

Comparison 4 Endoscopic stapler versus clips, Outcome 4 Comparison of operative time between stapler and clips.

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Comparison 4 Endoscopic stapler versus clips, Outcome 5 Comparison of hospital stay between stapler and clips.
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Analysis 4.5

Comparison 4 Endoscopic stapler versus clips, Outcome 5 Comparison of hospital stay between stapler and clips.

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Comparison 4 Endoscopic stapler versus clips, Outcome 6 Postoperative superficial infections.
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Analysis 4.6

Comparison 4 Endoscopic stapler versus clips, Outcome 6 Postoperative superficial infections.

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Comparison 4 Endoscopic stapler versus clips, Outcome 7 Postoperative deep infections.
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Analysis 4.7

Comparison 4 Endoscopic stapler versus clips, Outcome 7 Postoperative deep infections.

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Comparison 4 Endoscopic stapler versus clips, Outcome 8 Postoperative ileus.
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Analysis 4.8

Comparison 4 Endoscopic stapler versus clips, Outcome 8 Postoperative ileus.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.
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Analysis 5.1

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 5.2

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 5.3

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between mechanical device and ligature.
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Analysis 5.4

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between mechanical device and ligature.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Hospital stay (in days) between mechanical device and ligature.
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Analysis 5.5

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Hospital stay (in days) between mechanical device and ligature.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 5.6

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 5.7

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 5.8

Comparison 5 Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.
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Analysis 6.1

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 6.2

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 6.3

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between stapler and ligature.
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Analysis 6.4

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between stapler and ligature.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and ligature.
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Analysis 6.5

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and ligature.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 6.6

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 6.7

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 6.8

Comparison 6 Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.
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Analysis 7.1

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 1 Total complications.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 7.2

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 7.3

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between clips and ligature.
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Analysis 7.4

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 4 Comparison of operative time between clips and ligature.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between clips and ligature.
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Analysis 7.5

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 5 Comparison of hospital stay between clips and ligature.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 7.6

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 7.7

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 7.8

Comparison 7 Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model, Outcome 8 Postoperative ileus.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 1 Total complications.
Figures and Tables -
Analysis 8.1

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 1 Total complications.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 2 Intraoperative complications.
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Analysis 8.2

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 2 Intraoperative complications.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 3 Postoperative complications.
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Analysis 8.3

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 3 Postoperative complications.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 4 Comparison of operative time between stapler and clips.
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Analysis 8.4

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 4 Comparison of operative time between stapler and clips.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and clips.
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Analysis 8.5

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 5 Comparison of hospital stay between stapler and clips.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 6 Postoperative superficial infections.
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Analysis 8.6

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 6 Postoperative superficial infections.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 7 Postoperative deep infections.
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Analysis 8.7

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 7 Postoperative deep infections.

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Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 8 Postoperative ileus.
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Analysis 8.8

Comparison 8 Sensitivity analysis: endoscopic stapler versus clips using fixed effect model, Outcome 8 Postoperative ileus.

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Summary of findings for the main comparison. Mechanical devices versus ligature for appendix stump closure during laparoscopic appendectomy

Mechanical devices vs ligatures for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy
Setting: hospital
Intervention: mechanical devices (endoscopic stapler/clips)
Comparison: ligature (intra/extracorporeal knot/Endoloop)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with ligatures

Risk with mechanical devices

Total complications

205 per 1000

169 per 1000
(119 to 225)

OR 0.97

(0.27 to 3.50)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

76 per 1000

63 per 1000
(36 to 108)

OR 0.93

(0.34 to 2.55)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

129 per 1000

109 per 1000
(71 to 154)

OR 0.80

(0.21 to 3.13)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

26 per 1000

13 per 1000
(5 to 33)

OR 0.58
(0.18 to 1.93)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

41 per 1000

20 per 1000
(8 to 46)

OR 0.47
(0.19 to 1.18)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

14 per 1000

12 per 1000
(4 to 34)

OR 0.79
(0.24 to 2.53)

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was

40.6 minutes.

Mean operative time

(minutes) in the intervention

group was 9.04 minutes

shorter (12.97 minutes shorter to 5.11 minutes shorter).

‐

850
(8 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 1.4 days.

Mean hospital stay in the

intervention group was 0.02 days

longer (0.12 days shorter to 0.17 days longer).

‐

850
(8 RCTs)

⊕⊝⊝⊝
Very low1,2,3

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for inconsistency (substantial heterogeneity).

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (all included studies had few participants and events and thus wide confidence intervals, limiting the precision of estimates).

Figures and Tables -
Summary of findings for the main comparison. Mechanical devices versus ligature for appendix stump closure during laparoscopic appendectomy
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Summary of findings 2. Endoscopic stapler versus ligature for appendix stump closure during laparoscopic appendectomy

Endoscopic stapler vs ligature for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy

Settings: hospital

Intervention: endoscopic stapler

Comparison: ligature

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with ligature

Risk with endoscopic stapler

Total complications

421 per 1000

198 per 1000
(35 to 637)

OR 0.34 (0.05 to 2.41)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

182 per 1000

191 per 1000
(37 to 599)

OR 1.06 (0.17 to 6.70)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

239 per 1000

250 per 1000
(51 to 678)

OR 0.20 (0.09 to 0.44)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

44 per 1000

47 per 1000
(8 to 236)

OR 0.10 (0.01 to 0.84)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

88 per 1000

93 per 1000
(16 to 393)

OR 0.37 (0.13 to 1.07)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

31 per 1000

33 per 1000
(5 to 179)

OR 0.45 (0.10 to 2.08)

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was 40.6 minutes.

Mean operative time

in the intervention

group was 8.52 minutes

lower (15.64 minutes shorter to 1.39 minutes shorter).

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 1.9 days.

Mean hospital stay in the

intervention group was 0.02 days

longer (0.38 days shorter to 0.34 days longer).

327
(3 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level for inconsistency (substantial heterogeneity).

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (all included studies had few participants and events and thus wide confidence intervals, limiting the precision of estimates).

Figures and Tables -
Summary of findings 2. Endoscopic stapler versus ligature for appendix stump closure during laparoscopic appendectomy
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Summary of findings 3. Clips versus ligature for appendix stump closure during laparoscopic appendectomy

Clips vs ligatures for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy

Settings: hospital

Intervention: clips

Comparison: ligature

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with ligature

Risk with clips

Total complications

17 per 1000

18 per 1000
(3 to 105)

OR 2.03

(0.71 to 5.84)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

21 per 1000

22 per 1000
(4 to 124)

OR 1.74

(0.33 to 9.04)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

17 per 1000

18 per 1000
(3 to 105)

OR 1.88

(0.63 to 5.64)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

14 per 1000

15 per 1000
(2 to 86)

OR 1.25

(0.32 to 4.90)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

10 per 1000

11 per 1000
(2 to 65)

OR 0.92

(0.15 to 5.64)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

3 per 1000

4 per 1000
(1 to 23)

OR 1.75

(0.28 to 10.93)

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was

40.0 minutes.

Mean operative time

in the intervention

group was 8.14 minutes

shorter (11.73 minutes shorter

to 4.55 minutes shorter).

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 1.5 days.

Mean hospital stay in the

intervention group was 0.03 days

shorter (0.16 days shorter to 0.11

days longer).

553
(6 RCTs)

⊕⊝⊝⊝
Very lowa,b,c

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level for inconsistency (substantial heterogeneity).

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (all included studies had few participants and events and thus wide confidence intervals, limiting the precision of estimates).

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Summary of findings 3. Clips versus ligature for appendix stump closure during laparoscopic appendectomy
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Summary of findings 4. Endoscopic stapler versus clips for appendix stump closure during laparoscopic appendectomy

Endoscopic stapler vs clips for appendix stump closure during laparoscopic appendectomy

Patient or population: patients undergoing appendix stump closure during laparoscopic appendectomy

Settings: hospital

Intervention: endoscopic stapler

Comparison: clips

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Risk with clips

Risk with endoscopic stapler

Total complications

67 per 1000

70 per 1000
(12 to 324)

OR 1.00

(0.13 to 7.60)

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Intraoperative complications

67 per 1000

70 per 1000
(12 to 324)

OR 1.00

(0.13 to 7.60)

[60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative complications

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative superficial infections

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative ileus

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Postoperative deep infections

0 events in both treatment arms

NE

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Operative time (minutes)

Mean operative time was

39.4 minutes.

Mean operative time

in the intervention

group was 3.46 minutes

shorter (6.94 minutes shorter

to 0.02 minutes longer).

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Hospital stay (days)

Mean hospital stay

was 2.0 days.

Mean hospital stay in the

intervention group was 0.04 days

shorter (0.28 days shorter to 0.20

days longer).

60
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; NE: not estimable; OR: odds ratio; RCT: randomised controlled trial.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level for single study with limited sample size.

bDowngraded one level for high risk of bias.

cDowngraded one level for imprecision (the sole included studies had few participants and therefore few events, resulting in wide confidence intervals, which limited the precision of estimates).

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Summary of findings 4. Endoscopic stapler versus clips for appendix stump closure during laparoscopic appendectomy
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Table 1. Primary outcomes in included studies

Study ID

Intervention arms

Total no. with complications

Total no. without complications

Intraoperative

Postoperative

Bleeding

Intraoperative rupture of appendix

Intraoperative organ injury/ faecal soiling

Access‐related visceral injury

Other

Total

Surgical site infection (superficial)

Deep infection

Bleeding

Paralytic ileus

Purulent peritonitis

Other

Total

Ortega 1995

Endoscopic linear stapler (LAS)

27

51

11

2

5

0

0

18

0

2

0

5

0

2a

9

2× catgut ligatures (Endoloops) (LAL)

62

27

14

4

11

0

0

29

4

4

0

14

0

11b

33

Open appendectomy (OA)

44

42

20

5

1

0

0

26

11

0

0

6

0

1c

18

Akbiyik 2011

Hem‐o‐lok clip (non‐absorbable polymeric clips)

0

28

0

0

0

0

0

0

0

0

0

0

0

0

0

Ligaure (Endoloop)

0

21

0

0

0

0

0

0

0

0

0

0

0

0

0

Delibegovic 2012

45‐mm stapler

2

28

2

0

0

0

0

2

0

0

0

0

0

0

0

1 ligature (Endoloop)

0

30

0

0

0

0

0

0

0

0

0

0

0

0

0

1 Hem‐o‐lok clip (non‐absorbable polymeric clips)

2

28

2

0

0

0

0

2

0

0

0

0

0

0

0

Beldi 2004

1 ligature (Endoloop) only at appendix base (1 other at 6 to 12 mm distally)

5

104

0

0

0

0

0

0

0

3

0

0

0

2d

5

2 ligatures (Endoloops) at base of appendix (1 other at 6 to 12 mm distally)

5

94

0

0

0

0

0

0

0

4

0

0

0

1e

5

Sucullu 2009

Endodissector and endoclip

0

16

0

0

0

0

0

0

0

0

0

0

0

0

0

LigaSure 5 to 10 mm

0

16

0

0

0

0

0

0

0

0

0

0

0

0

0

Shalaby 2001

Endo GIA (Ethicon Endo‐Surgery, Cincinnati, Ohio, USA) stapler

0

60

0

0

0

0

0

0

0

0

0

0

0

0

0

Ligature (Endoloop)

5

35

0

0

0

0

0

0

3

1

0

0

0

1f

5

Extracorporeal laparoscopically assisted appendectomy

6

44

0

0

0

0

0

0

2

1

1

0

0

0

4

Colak 2013

Hem‐o‐lok (non‐absorbable polymeric clips)

3

23

0

0

0

0

0

0

2

0

0

0

0

1g

3

Ligature (Endoloop)

3

24

0

0

0

0

0

0

1

1

0

0

0

1g

3

Gonenc 2012

Titanium endoclip

4

57

1

0

0

0

0

1

1

1

0

1

0

0

3

Intracorporeal knotting

6

40

0

0

1

1

0

2

1

0

0

2

1

0

4

Ates 2012

Titanium endoclip

8

22

NS

NS

NS

NS

1h

7

0

1

0

0

0

0

1

Intracorporeal knotting

7

24

NS

NS

NS

NS

0

4

1

0

0

0

0

2i

3

Yang 2014

Intracorporeal knotting

5

125

0

NS

NS

NS

NS

0

NS

0

NS

NS

NS

5j

5

Titanium hem‐o‐lok

17

69

0

NS

NS

NS

NS

0

NS

0

NS

NS

NS

17k

17

Nadeem 2015

Extracorporeal knotting

5

31

1

NS

0

NS

NS

1

2

0

NS

1

NS

1

4

Metallic endoclip

10

22

2

NS

1

NS

NS

3

2

2

NS

2

NS

1l

7

NS: non‐significant.
aTwo cases of vomiting. bEleven cases of vomiting. cone case of vomiting. dOne case of pulmonary embolism (PE) and one case of persistent port site pain. eOne case of prolonged percutaneous drainage. fOne case of intestinal obstruction. gOne non‐surgical complication. ihTwo open endoclips dropped during procedure and discovered by abdominal X‐ray postoperatively. iOne case of abdominal pain and one case unknown. jThree cases of lower abdominal discomfort, one case of abdominal pain, and two cases of fever. kEight cases of lower abdominal discomfort, three cases of abdominal pain, five cases of fever, and one reoperation. lOne re‐admission occurred in each arm: The re‐admitted participant in the metallic endoclip arm required peritoneal lavage and drain placement.

Figures and Tables -
Table 1. Primary outcomes in included studies
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Table 2. Sensitivity analyses

Mechanical appendix stump closure (with endoscopic stapler or clip(s)) vs ligation (with Endoloop or intra/extracorporeal knot)

Odds ratio (95% CI)

Risk ratio (95% CI)

Risk difference (95% CI)

Mean difference (95% CI)

Outcome

Fixed effect

Random effects

Fixed effect

Random effects

Fixed effect

Random effects

Fixed effect

Random effects

Total complications

0.77 (0.53 to 1.13)

0.97 (0.27 to 3.50)

0.83 (0.64 to 1.08)

1.09 (0.41 to 2.88)

‐0.03 (‐0.08 to 0.01)

‐0.02 (‐0.12 to 0.09)

‐

‐

Intraoperative complications

0.81 (0.45 to 1.46)

0.93 (0.34 to 2.55)

0.85 (0.53 to 1.35)

0.93 (0.40 to 2.18)

‐0.01 (‐0.04 to 0.02)

0.00 (‐0.02 to 0.02)

‐

‐

Postoperative complications

0.80 (0.52 to 1.24)

0.80 (0.21 to 3.13)

0.83 (0.57 to 1.19)

0.86 (0.27 to 2.74)

‐0.02 (‐0.06 to 0.02)

‐0.02 (‐0.10 to 0.06)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐11.94 (‐13.04 to ‐10.84)

‐9.04 (‐12.97 to ‐5.11)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

0.02 (‐0.12 to 0.16)

0.02 (‐0.12 to 0.17)

Postoperative superficial infections

0.47 (0.17 to 1.26)

0.58 (0.18 to 1.93)

0.48 (0.19 to 1.24)

0.61 (0.19 to 1.93)

‐0.02 (‐0.04 to 0.01)

‐0.01 (‐0.02 to 0.01)

‐

‐

Postoperative ileus

0.48 (0.20 to 1.15)

0.47 (0.19 to 1.18)

0.51 (0.23 to 1.14)

0.50 (0.22 to 1.17)

‐0.02 (‐0.04 to 0.01)

‐0.01 (‐0.03 to 0.02)

‐

‐

Postoperative deep infections

0.86 (0.31 to 2.41)

0.79 (0.24 to 2.53)

0.87 (0.32 to 2.35)

0.79 (0.25 to 2.47)

‐0.00 (‐0.02 to 0.02)

‐0.00 (‐0.02 to 0.01)

‐

‐

Endoscopic stapler vs ligature

Total complications

0.26 (0.14 to 0.46)

0.34 (0.05 to 2.41)

0.49 (0.35 to 0.68)

0.51 (0.09 to 2.84)

‐0.21 (‐0.29 to ‐0.12)

‐0.13 (‐0.40 to 0.14)

‐

‐

Intraoperative complications

0.72 (0.38 to 1.39)

1.06 (0.17 to 6.70)

0.79 (0.48 to 1.28)

1.07 (0.22 to 5.19)

‐0.04 (‐0.11 to 0.04)

‐0.00 (‐0.11 to 0.10)

‐

‐

Postoperative complications

0.19 (0.09 to 0.41)

0.20 (0.09 to 0.44)

0.27 (0.14 to 0.51)

0.25 (0.08 to 0.75)

‐0.17 (‐0.24 to ‐0.10)

‐0.12 (‐0.34 to 0.09)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐12.94 (‐14.35 to ‐11.53)

‐8.36 (‐15.68 to ‐1.03)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

0.03 (‐0.14 to 0.20)

‐0.02 (‐0.38 to 0.34)

Postoperative superficial infections

0.10 (0.01 to 0.86)

0.10 (0.01 to 0.84)

0.11 (0.01 to 0.88)

0.11 (0.01 to 0.87)

‐0.05 (‐0.08 to ‐0.01)

‐0.04 (‐0.08 to 0.00)

‐

‐

Postoperative ileus

0.37 (0.13 to 1.07)

0.37 (0.13 to 1.07)

0.41 (0.15 to 1.08)

0.41 (0.15 to 1.08)

‐0.05 (‐0.10 to 0.00)

‐0.02 ( ‐0.10 to 0.05)

‐

‐

Postoperative deep infections

0.45 (0.10 to 2.02)

0.45 (0.10 to 2.08)

0.46 (0.11 to 1.95)

0.47 (0.11 to 2.04)

‐0.02 (‐0.05 to 0.02)

‐0.02 (‐0.05 to 0.02)

‐

‐

Endoscopic stapler vs clips

Total complications

1.00 (0.13 to 7.60)

1.00 (0.13 to 7.60)

1.00 (0.15 to 6.64)

1.00 (0.15 to 6.64)

0.00 (‐0.13 to 0.13)

0.00 (‐0.13 to 0.13)

‐

‐

Intraoperative complications

1.00 (0.13 to 7.60)

1.00 (0.13 to 7.60)

1.00 (0.15 to 6.64)

1.00 (0.15 to 6.64)

0.00 (‐0.13 to 0.13)

0.00 (‐0.13 to 0.13)

‐

‐

Postoperative complications

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐3.46 (‐6.94 to 0.02)

‐3.46 (‐6.94 to 0.02)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

‐0.04 (‐0.28 to 0.20)

‐0.04 [‐0.28, 0.20]

Postoperative superficial infections

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Postoperative ileus

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Postoperative deep infections

NE

NE

NE

NE

0.00 (‐0.06 to 0.06)

0.00 (‐0.06 to 0.06)

‐

‐

Clips vs ligature (Endoloop and intra/extracorporeal knot)

Total complications

2.33 (1.31 to 4.13)

2.03 (0.71 to 5.84)

2.11 (1.29 to 3.47)

1.84 (0.73 to 4.62)

0.08 (0.03 to 0.13)

0.05 (‐0.03 to 0.13)

‐

‐

Intraoperative complications

1.79 (0.49 to 6.56)

1.74 (0.33 to 9.04)

1.76 (0.51 to 6.01)

1.69 (0.35 to 8.19)

0.01 (‐0.02 to 0.04)

0.00 (‐0.02 to 0.02)

‐

‐

Postoperative complications

2.40 (1.28 to 4.48)

1.88 (0.63 to 5.64)

2.20 (1.27 to 3.82)

1.75 (0.66 to 4.61)

0.07 (0.02 to 0.12)

0.03 (‐0.04 to 0.11)

‐

‐

Operative time (minutes)

‐

‐

‐

‐

‐

‐

‐8.06 (‐9.85 to ‐6.26)

‐8.14 (‐11.73 to ‐4.55)

Hospital stay (days)

‐

‐

‐

‐

‐

‐

‐0.03 (‐0.16 to 0.11)

‐0.03 (‐0.16 to 0.11)

Postoperative superficial infections

1.27 (0.33 to 4.86)

1.25 (0.32 to 4.90)

1.25 (0.35 to 4.49)

1.24 (0.34 to 4.56)

0.00 (‐0.02 to 0.03)

0.00 (‐0.02 to 0.02)

‐

‐

Postoperative ileus

0.92 (0.19 to 4.56)

0.92 (0.15 to 5.64)

0.92 (0.20 to 4.21)

0.93 (0.16 to 5.33)

‐0.00 (‐0.02 to 0.02)

‐0.00 (‐0.02 to 0.02)

‐

‐

Postoperative deep infections

1.79 (0.37 to 8.58)

1.75 (0.28 to 10.93)

1.77 (0.38 to 8.16)

1.71 (0.28 to 10.28)

0.01 (‐0.02 to 0.03)

0.00 (‐0.01 to 0.02)

‐

‐

CI: confidence interval; NE: not estimable; "‐": not applicable.
Figures and Tables -
Table 2. Sensitivity analyses
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Comparison 1. Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.97 [0.27, 3.50]

2 Intraoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.93 [0.34, 2.55]

3 Postoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.80 [0.21, 3.13]

4 Comparison of operative time between mechanical device and ligature Show forest plot

8

850

Mean Difference (IV, Random, 95% CI)

‐9.04 [‐12.97, ‐5.11]

5 Hospital stay (in days) between mechanical and ligature Show forest plot

8

850

Mean Difference (IV, Random, 95% CI)

0.02 [‐0.12, 0.17]

6 Postoperative superficial infections Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.58 [0.18, 1.93]

7 Postoperative deep infections Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.79 [0.24, 2.53]

8 Postoperative ileus Show forest plot

8

850

Odds Ratio (M‐H, Random, 95% CI)

0.47 [0.19, 1.18]
Figures and Tables -
Comparison 1. Mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot)
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Comparison 2. Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.34 [0.05, 2.41]

2 Intraoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

1.06 [0.17, 6.70]

3 Postoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.20 [0.09, 0.44]

4 Comparison of operative time between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Random, 95% CI)

‐8.52 [‐15.64, ‐1.39]

5 Comparison of hospital stay between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Random, 95% CI)

‐0.02 [‐0.38, 0.34]

6 Postoperative superficial infections Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.10 [0.01, 0.84]

7 Postoperative deep infections Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.45 [0.10, 2.08]

8 Postoperative ileus Show forest plot

3

327

Odds Ratio (M‐H, Random, 95% CI)

0.37 [0.13, 1.07]
Figures and Tables -
Comparison 2. Endoscopic stapler versus ligature (with Endoloop or intracorporeal knot)
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Comparison 3. Clips versus ligature (Endoloop or intracorporeal knot)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

2.03 [0.71, 5.84]

2 Intraoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.74 [0.33, 9.04]

3 Postoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.88 [0.63, 5.64]

4 Comparison of operative time between clips and ligatures Show forest plot

6

553

Mean Difference (IV, Random, 95% CI)

‐8.14 [‐11.73, ‐4.55]

5 Comparison of hospital stay between clips and ligature Show forest plot

6

553

Mean Difference (IV, Random, 95% CI)

‐0.03 [‐0.16, 0.11]

6 Postoperative superficial infections Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.25 [0.32, 4.90]

7 Postoperative deep infections Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

1.75 [0.28, 10.93]

8 Postoperative ileus Show forest plot

6

553

Odds Ratio (M‐H, Random, 95% CI)

0.92 [0.15, 5.64]
Figures and Tables -
Comparison 3. Clips versus ligature (Endoloop or intracorporeal knot)
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Comparison 4. Endoscopic stapler versus clips

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

1.0 [0.13, 7.60]

2 Intraoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

1.0 [0.13, 7.60]

3 Postoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

4 Comparison of operative time between stapler and clips Show forest plot

1

60

Mean Difference (IV, Random, 95% CI)

‐3.46 [‐6.94, 0.02]

5 Comparison of hospital stay between stapler and clips Show forest plot

1

60

Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.28, 0.20]

6 Postoperative superficial infections Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

7 Postoperative deep infections Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

8 Postoperative ileus Show forest plot

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 4. Endoscopic stapler versus clips
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Comparison 5. Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.77 [0.53, 1.13]

2 Intraoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.81 [0.45, 1.46]

3 Postoperative complications Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.80 [0.52, 1.24]

4 Comparison of operative time between mechanical device and ligature Show forest plot

8

850

Mean Difference (IV, Fixed, 95% CI)

‐11.94 [‐13.04, ‐10.84]

5 Hospital stay (in days) between mechanical device and ligature Show forest plot

8

850

Mean Difference (IV, Fixed, 95% CI)

0.02 [‐0.12, 0.16]

6 Postoperative superficial infections Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.47 [0.17, 1.26]

7 Postoperative deep infections Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.86 [0.31, 2.41]

8 Postoperative ileus Show forest plot

8

850

Odds Ratio (M‐H, Fixed, 95% CI)

0.48 [0.20, 1.15]
Figures and Tables -
Comparison 5. Sensitivity analysis: mechanical appendix stump closure (with endoscopic stapler or clip(s)) versus ligation (with Endoloop or intracorporeal knot) using fixed effect model
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Comparison 6. Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.26 [0.14, 0.46]

2 Intraoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.72 [0.38, 1.39]

3 Postoperative complications Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.19 [0.09, 0.41]

4 Comparison of operative time between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Fixed, 95% CI)

‐12.99 [‐14.39, ‐11.58]

5 Comparison of hospital stay between stapler and ligature Show forest plot

3

327

Mean Difference (IV, Fixed, 95% CI)

0.03 [‐0.14, 0.20]

6 Postoperative superficial infections Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.10 [0.01, 0.86]

7 Postoperative deep infections Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.45 [0.10, 2.02]

8 Postoperative ileus Show forest plot

3

327

Odds Ratio (M‐H, Fixed, 95% CI)

0.37 [0.13, 1.07]
Figures and Tables -
Comparison 6. Sensitivity analysis: endoscopic stapler versus ligature (with Endoloop or intracorporeal knot) using fixed effect model
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Comparison 7. Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

2.33 [1.31, 4.13]

2 Intraoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

1.79 [0.49, 6.56]

3 Postoperative complications Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

2.40 [1.28, 4.48]

4 Comparison of operative time between clips and ligature Show forest plot

6

553

Mean Difference (IV, Fixed, 95% CI)

‐8.06 [‐9.85, ‐6.26]

5 Comparison of hospital stay between clips and ligature Show forest plot

6

553

Mean Difference (IV, Fixed, 95% CI)

‐0.03 [‐0.16, 0.11]

6 Postoperative superficial infections Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

1.27 [0.33, 4.86]

7 Postoperative deep infections Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

1.79 [0.37, 8.58]

8 Postoperative ileus Show forest plot

6

553

Odds Ratio (M‐H, Fixed, 95% CI)

0.92 [0.19, 4.56]
Figures and Tables -
Comparison 7. Sensitivity analysis: clips versus ligature (Endoloop or intracorporeal knot) using fixed effect model
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Comparison 8. Sensitivity analysis: endoscopic stapler versus clips using fixed effect model

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total complications Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

1.0 [0.13, 7.60]

2 Intraoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

1.0 [0.13, 7.60]

3 Postoperative complications Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Comparison of operative time between stapler and clips Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐3.46 [‐6.94, 0.02]

5 Comparison of hospital stay between stapler and clips Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐0.04 [‐0.28, 0.20]

6 Postoperative superficial infections Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7 Postoperative deep infections Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8 Postoperative ileus Show forest plot

1

60

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 8. Sensitivity analysis: endoscopic stapler versus clips using fixed effect model
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